Health Appraisal - MDCH/BCAL-3305

HEALTH APPRAISAL

Dear Parent or Guardian: The following information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs

of the child. Fill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The

remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD¡¯S IMMUNIZATION RECORDS TO THE EXAMINATION.)

PERSONAL

CHILD¡¯S NAME (Last, First, Middle)

DATE OF BIRTH (mm/dd/yy)

/ /

ADDRESS (Number & Street)

(City)

(ZIP Code)

TODAY¡¯S DATE (mm/dd/yy)

MI

/ /

PARENT/GUARDIAN (Last, First, Middle)

HOME TELEPHONE NUMBER

( )

ADDRESS (Number & Street)

(City)

(ZIP Code)

WORK TELEPHONE NUMBER

MI

( )

Resolved

SECTION I - HEALTH HISTORY

No

Yes

? # Is your child having any of the problems listed below?

h h h ? 1 Allergies or Reactions (for example, food, medication or other)

h h h ? 2 Hay Fever, Asthma, or Wheezing

h h h ? 3 Eczema or Frequent Skin Rashes

h h h ?4 Convulsions/Seizures

h h h ? 5 Heart Trouble

h h h ?6 Diabetes

h h h ? 7 Frequent Colds, Sore Throats, Earaches (4 or more per year)

h h h ? 8 Trouble with Passing Urine or Bowel Movements

h h h ? 9 Shortness of Breath

h h h 10 Speech Problems

h h h 11 Menstrual Problems

h h h 12 Dental Problems: Date of Last Exam

/

/

h h h Other (please describe):

h h

Does your child take any medication(s) regularly?

Reason for Medication

Birth History:

Are there any current or past diagnosis(es)

If yes, please describe:

[

/ /

Parent/Guardian Signature ?

Date

h Yes??h No

If yes, list medications:

Was the health history reviewed by a health professional?

h Yes??h No

Examiner¡¯s Initials:

SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS

Required for Child Care and Head Start / Early Head Start

HEIGHT & WEIGHT

h h

h h

Other:

h h

BLOOD PRESSURE

Reading:

TUBERCULIN

Type:

Date: / /

Neg.: h??Pos.: h

Muscle Imbalance

h h

Date: / /

Audiometer

Other:

h h

Date: / /

URINALYSIS

Sugar

Albumin

h h

Date: / /

Level

h h

[

ug/dl ??

Date: / /

Under Care

Other

]

HEMOGLOBIN / HEMATOCRIT

h h

Microscopic

BLOOD LEAD LEVEL

Height

Weight

Other:

HEARING

Test results:

h h

Referred

Was child tested for:

Normal

Yes

Under Care

Visual Acuity

No

Test results:

VISION

Referred

Was child tested for:

Normal

Yes

No

Tests and Measurements

mm

NOTE: Blood lead level required for all children enrolled in Medicaid must be tested

at one and two years of age, or once between three and six years of age if not

previously tested. All children under age six living in high-risk areas should be tested

at the same intervals as listed above.

Examinations and/or Inspections

Essential Findings Deviating from Normal:

Exam Date:????

/????

/

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Rev. July 2015

SECTION III - IMMUNIZATIONS

Statements such as ¡°UP-TO-DATE¡± or ¡°COMPLETE¡± will not be accepted. Admission to school may be denied on the basis of this information.*

DATE ADMINISTERED

VACCINES (Circle Type)

Hepatitis B

1

(HepB)

2

DTaP/DTP/DT/Td

DATE ADMINISTERED

VACCINES (Circle Type)

MM/DD/YYYY

Hepatitis A (HepA)

3

Influenza (IIV/LAIV)

MM/DD/YYYY

1

2

1

3

2

4

1

4

2

5

Meningococcal (MCV4 / MPSV4)

1

2

3

6

Human Papillomavirus

1

3

(HPV9/HPV4/HPV2)

2

Tdap

1

Haemophilus Influenzae

1

3

type b (HIB)

2

4

OTHER Vaccines

1

Specify Date & Type

2

Type of Vaccine(s)

Date of Vaccine(s)

Polio

1

3

(IPV/OPV)

2

4

Pneumococcal Conjugate

1

3

Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable

(PCV7/PCV13)

2

4

Rotavirus (RV1/RV5)

1

3

*NOTE: According to Public Act 368 of 1978, any child enrolling in a Michigan school for

the first time must be adequately immunized, vision tested and hearing tested.

Exemptions to these requirements are granted for medical, religious and other

objections, provided that the waiver forms are properly prepared, signed and

delivered to school administrators. Forms for these exemptions are available

at your provider office for medical waiver forms and through your local health

department for nonmedical waiver forms.

Parent/Guardian refused immunizations: h

3

2

Measles,Mumps, Rubella (MMR)

1

2

Varicella (Chickenpox)

1

2

History of Chickenpox Disease??? h Yes??h No???If yes, date:

I certify that the immunization dates are true to the best of my knowledge

/?????

Title

Health Professional¡¯s Signature

/

Date

Yes

No

SECTION IV - RECOMMENDATIONS

(Required for Child Care and Head Start/Early Head Start)

h h

Is there any defect of vision, hearing or other condition for which the school could help by seating or other actions? If yes, please explain:

h h

Should the child¡¯s activity be restricted because of any physical defect or illness?

If yes, check and explain degree of restriction(s):

h Classroom??h Playground??h Gymnasium??h Swimming Pool??h Competitive Sports??h Other

Other Recommendations

SECTION V - DENTAL EXAMINATION AND RECOMMENDATIONS (OPTIONAL)

I have examined

child¡¯s name

¡¯s teeth. As a result of this examination, my recommendation for treatment is:

/ ??

/

Dentist¡¯s Signature ??

Date

PHYSICIAN¡¯S SIGNATURE

??

Examiner¡¯s Signature

??

/

/

Date

Number & Street

Examiner¡¯s Name (Print or Type) ?? Degree or License

MI

( ??

)

City ?

ZIP Code

Telephone

Information required for:

Early On - Hearing and Vision Status; Diagnosis; Health Status

Child Care Licensing - Physical Exam, Restrictions, Immunizations

Head Start/Early Head Start - Determination that child is up-to-date on a schedule of age-appropriate preventive and primary health care, including

medical, dental, and mental health. The schedule must incorporate the well-child care visit required by EPSDT and the latest immunizations schedule

recommended by the Centers for Disease Control and Prevention, State, tribal, and local authorities. An EPSDT well-child exam includes height, weight,

and blood tests for anemia at regular intervals based on age.

**************

Developed in Cooperation with the Department of Health and Human Services, Education, Michigan American Association of Pediatrics, Early

Childhood Investment Corporation, Child Care Licensing, Head Start, Michigan State Medical Society, Michigan Association of Osteopathic

Physicians and Surgeons.

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Rev. July 2015

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